Melanoma II (Diagnosis and Treatment)
Melanoma II (Diagnosis and Treatment)
If the doctor suspects that a spot on the skin is melanoma, the patient will need to have a biopsy. A biopsy is the only way to make a definite diagnosis. In this procedure, the doctor tries to remove all of the suspicious-looking growth. This is an excisional biopsy. If the growth is too large to be removed entirely, the doctor removes a sample of the tissue. The doctor will never "shave off" or cauterize a growth that might be melanoma.
A biopsy can usually be done in the doctor's office using local anesthesia. A pathologist then examines the tissue under a microscope to check for cancer cells. Sometimes it is helpful for more than one pathologist to check the tissue for cancer cells.
A person who needs a biopsy may want to ask the doctor the following questions:
- Why do I need a biopsy?
- How long will it take? Will it hurt?
- Will the entire tumor be removed?
- What side effects can I expect?
- How soon will I know the results?
- If I do have cancer, who will talk to me about treatment? When?
If the diagnosis is melanoma, the doctor needs to learn the extent, or stage, of the disease before planning treatment. Staging is a careful attempt to learn how thick the tumor is, how deeply the melanoma has invaded the skin, and whether melanoma cells have spread to nearby lymph nodes or other parts of the body. The doctor may remove nearby lymph nodes to check for cancer cells. (Such surgery may be considered part of the treatment because removing cancerous lymph nodes may help control the disease.) The doctor also does a careful physical exam and, if the tumor is thick, may order chest x-rays, blood tests, and scans of the liver, bones, and brain.
Stages of Melanoma
The following stages are used for melanoma:
In stage 0, the melanoma cells are found only in the outer layer of skin cells and have not invaded deeper tissues.
- Melanoma in stage I is thin.
- The tumor is no more than 1 millimeter (1/25 inch) thick. The outer layer (epidermis) of skin may appear scraped. (This is called an ulceration).
- Or, the tumor is between 1 and 2 millimeters (1/12 inch) thick. There is no ulceration.
- The melanoma cells have not spread to nearby lymph nodes.
- The tumor is at least 1 millimeter thick:o The tumor is between 1 and 2 millimeters thick. There is ulceration.
- Or, the thickness of the tumor is more than 2 millimeters. There may be ulceration.
- The melanoma cells have not spread to nearby lymph nodes.
- The melanoma cells have spread to nearby tissues.
- The melanoma cells have spread to one or more nearby lymph nodes.
- Or, the melanoma cells have spread to tissues just outside the original tumor but not to any lymph nodes.
- The melanoma cells have spread to other organs, to lymph nodes, or to skin areas far away from the original tumor.
- Recurrent: Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may have come back in the original site or in another part of the body.
The doctor can describe treatment choices and discuss the results expected with each treatment option. The doctor and patient can work together to develop a treatment plan that fits the patient's needs. Treatment for melanoma depends on the extent of the disease, the patient's age and general health, and other factors.
People with melanoma are often treated by a team of specialists. The team may include a dermatologist, surgeon, medical oncologist, radiation oncologist, and plastic surgeon.
Getting a Second Opinion
Before starting treatment, the patient might want a second opinion about the diagnosis and the treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if the patient or doctor requests it.
There are a number of ways to find a doctor for a second opinion:o The patient's doctor may refer the patient to one or more specialists. At cancer centers, several specialists often work together as a team.
- The Cancer Information Service, at 1-800-4-CANCER, can tell callers about nearby treatment centers.
A local or state medical society, a nearby hospital, or a medical school can usually provide the names of specialists.
- The Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their specialty and their educational background. Board-certified doctors have met specific education and training requirements and have passed an examination given by a specialty board. The directory is available in most public libraries. The American Board of Medical Specialties (ABMS) also offers information about board certification by telephone and on the Internet. The toll-free telephone number is 1-866-ASK-ABMS (1-866-275-2267). The Internet address is http://www.abms.org/newsearch.asp.
Preparing for Treatment
People with melanoma often want to take an active part in making decisions about their medical care. They want to learn all they can about their disease and their treatment choices. However, shock and stress after a diagnosis of a melanoma can make it hard to think of everything to ask the doctor. It often helps to make a list of questions before an appointment. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some also want to have a family member or friend with them when they talk to the doctor - to take part in the discussion, to take notes, or just to listen.
These are some questions a person may want to ask the doctor before treatment begins:
- What is my diagnosis?
- What is the stage of my disease?
- What are my treatment choices? Which do you recommend for me? Why?
- What are the benefits of each kind of treatment?
- What are the risks and possible side effects of each treatment?
- How will I feel after surgery?
- If I have pain, how will it be controlled?
- Will I need more treatment after surgery?
- Will there be a scar? Will I need a skin graft or plastic surgery?
- What is the treatment likely to cost?
- Will treatment affect my normal activities? If so, for how long?
- How often will I need checkups?
- Would a clinical trial (research study) be appropriate for me? Can you help me find one?
People do not need to ask all of their questions or understand all of the answers at one time. They will have other chances to ask the doctor to explain things that are not clear and to ask for more information.
Methods of Treatment
People with melanoma may have surgery, chemotherapy, biological therapy, or radiation therapy. Patients may have a combination of treatments.
At any stage of disease, people with melanoma may have treatment to control pain and other symptoms of the cancer, to relieve the side effects of therapy, and to ease emotional and practical problems. This kind of treatment is called symptom management, supportive care, or palliative care.
The doctor is the best person to describe the treatment choices and discuss the expected results.
A patient may want to talk to the doctor about taking part in a clinical trial, a research study of new treatment methods. The section on "The Promise of Cancer Research" has more information about clinical trials.
Surgery is the usual treatment for melanoma. The surgeon removes the tumor and some normal tissue around it. This procedure reduces the chance that cancer cells will be left in the area. The width and depth of surrounding skin that needs to be removed depends on the thickness of the melanoma and how deeply it has invaded the skin:
- The doctor may be able to completely remove a very thin melanoma during the biopsy. Further surgery may not be necessary.
- If the melanoma was not completely removed during the biopsy, the doctor takes out the remaining tumor. In most cases, additional surgery is performed to remove normal-looking tissue around the tumor (called the margin) to make sure all melanoma cells are removed. This is often necessary, even for thin melanomas. If the melanoma is thick, the doctor may need to remove a larger margin of tissue.
If a large area of tissue is removed, the surgeon may do a skin graft. For this procedure, the doctor uses skin from another part of the body to replace the skin that was removed.
Lymph nodes near the tumor may be removed because cancer can spread through the lymphatic system. If the pathologist finds cancer cells in the lymph nodes, it may mean that the disease has also spread to other parts of the body. Two procedures are used to remove the lymph nodes:
- Sentinel lymph node biopsy - The sentinel lymph node biopsy is done after the biopsy of the melanoma but before the wider excision of the tumor. A radioactive substance is injected near the melanoma. The surgeon follows the movement of the substance on a computer screen. The first lymph node(s) to take up the substance is called the sentinel lymph node(s). (The imaging study is called lymphoscintigraphy. The procedure to identify the sentinel node(s) is called sentinel lymph node mapping.) The surgeon removes the sentinel node(s) to check for cancer cells.
If a sentinel node contains cancer cells, the surgeon removes the rest of the lymph nodes in the area. However, if a sentinel node does not contain cancer cells, no additional lymph nodes are removed.
- Lymph node dissection - The surgeon removes all the lymph nodes in the area of the melanoma.
Therapy may be given after surgery to kill cancer cells that remain in the body. This treatment is called adjuvant therapy. The patient may receive biological therapy.
Surgery is generally not effective in controlling melanoma that has spread to other parts of the body. In such cases, doctors may use other methods of treatment, such as chemotherapy, biological therapy, radiation therapy, or a combination of these methods.
Chemotherapy, the use of drugs to kill cancer cells, is sometimes used to treat melanoma. The drugs are usually given in cycles: a treatment period followed by a recovery period, then another treatment period, and so on. Usually a patient has chemotherapy as an outpatient (at the hospital, at the doctor's office, or at home). However, depending on which drugs are given and the patient's general health, a short hospital stay may be needed.
People with melanoma may receive chemotherapy in one of the following ways:
- By mouth or injection - Either way, the drugs enter the bloodstream and travel throughout the body.
- Isolated limb perfusion (also called isolated arterial perfusion)
- For melanoma on an arm or leg, chemotherapy drugs are put directly into the bloodstream of that limb. The flow of blood to and from the limb is stopped for a while. This allows most of the drug to reach the tumor directly. Most of the chemotherapy remains in that limb.
The drugs may be heated before injection. This type of chemotherapy is called hyperthermic perfusion.
Biological therapy (also called immunotherapy) is a form of treatment that uses the body's immune system, either directly or indirectly, to fight cancer or to reduce side effects caused by some cancer treatments. Biological therapy for melanoma uses substances called cytokines. The body normally produces cytokines in small amounts in response to infections and other diseases. Using modern laboratory techniques, scientists can produce cytokines in large amounts. In some cases, biological therapy given after surgery can help prevent melanoma from recurring. For patients with metastatic melanoma or a high risk of recurrence, interferon alpha and interleukin-2 (also called IL-2 or aldesleukin) may be recommended after surgery.
Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. A large machine directs radiation at the body. The patient usually has treatment at a hospital or clinic, five days a week for several weeks. Radiation therapy may be used to help control melanoma that has spread to the brain, bones, and other parts of the body. It may shrink the tumor and relieve symptoms.
Treatment Choices by Stage
The following are brief descriptions of the treatments most often used for each stage. (Other treatments may sometimes be appropriate.)
People with Stage 0 melanoma may have minor surgery to remove the tumor and some of the surrounding tissue.
People with Stage I melanoma may have surgery to remove the tumor. The surgeon may also remove as much as 2 centimeters (3/4 inch) of tissue around the tumor. To cover the wound, the patient may have skin grafting.
Stage II or Stage III
People with Stage II or Stage III melanoma may have surgery to remove the tumor. The surgeon may also remove as much as 3 centimeters (1 1/4 inches) of nearby tissue. Skin grafting may be done to cover the wound. Sometimes the surgeon removes nearby lymph nodes.
People with Stage IV melanoma often receive palliative care. The goal of palliative care is to help the patient feel better - physically and emotionally. This type of treatment is intended to control pain and other symptoms and to relieve the side effects of therapy (such as nausea), rather than to extend life.
The patient may have one of the following:
- Surgery to remove lymph nodes that contain cancer cells or to remove tumors that have spread to other areas of the body
- Radiation therapy, biological therapy, or chemotherapy to relieve symptoms
People with advanced melanoma can find helpful information in the National Cancer Institute booklet Pain Control: A Guide for People with Cancer and Their Families.
Treatment for recurrent melanoma depends on where the cancer came back, which treatments the patient has already received, and other factors. As with Stage IV melanoma, treatment usually cannot cure melanoma that recurs. Palliative care is often an important part of the treatment plan. Many patients have palliative care to ease their symptoms while they are getting anticancer treatments to slow the progress of the disease. Some receive only palliative care to improve their quality of life by easing pain, nausea, and other symptoms.
The patient may have one of the following:
- Surgery to remove the tumor
- Radiation therapy, biological therapy, or chemotherapy to relieve symptoms
- Heated chemotherapy drugs injected directly into the tumor
Side Effects of Treatment
Because treatment may damage healthy cells and tissues, unwanted side effects sometimes occur. These side effects depend on many factors, including the location of the tumor and the type and extent of the treatment. Side effects may not be the same for each person, and they may even change from one treatment session to the next. Before treatment starts, the health care team will explain possible side effects and suggest ways to help the patient manage them.
The NCI provides helpful booklets about cancer treatments and coping with side effects, such as Radiation Therapy and You, Chemotherapy and You, and Eating Hints for Cancer Patients. See the sections "National Cancer Institute Information Resources" and "National Cancer Institute Booklets" for other sources of information about side effects.
Side Effects of Surgery
The side effects of surgery depend mainly on the size and location of the tumor and the extent of the operation. Although patients may have some pain during the first few days after surgery, this pain can be controlled with medicine. People should feel free to discuss pain relief with the doctor or nurse. It is also common for patients to feel tired or weak for a while. The length of time it takes to recover from an operation varies for each patient.
Scarring may also be a concern for some patients. To avoid causing large scars, doctors remove as little tissue as they can (while still protecting against recurrence). In general, the scar from surgery to remove an early stage melanoma is a small line (often 1 to 2 inches long), and it fades with time. How noticeable the scar is depends on where the melanoma was, how well the person heals, and whether the person develops raised scars called keloids. When a tumor is large and thick, the doctor must remove more surrounding skin and other tissue (including muscle). Although skin grafts reduce scarring caused by the removal of large growths, these scars will still be quite noticeable.
Surgery to remove the lymph nodes from the underarm or groin may damage the lymphatic system and slow the flow of lymphatic fluid in the arm or leg. Lymphatic fluid may build up in a limb and cause swelling (lymphedema). The doctor or nurse can suggest exercises or other ways to reduce swelling if it becomes a problem. Also, it is harder for the body to fight infection in a limb after nearby lymph nodes have been removed, so the patient will need to protect the arm or leg from cuts, scratches, bruises, insect bites, or burns that may lead to infection. If an infection does develop, the patient should see the doctor right away.
Side Effects of Chemotherapy
The side effects of chemotherapy depend mainly on the specific drugs and the dose. In general, anticancer drugs affect cells that divide rapidly, especially:o Blood cells: These cells fight infection, help the blood to clot, and carry oxygen to all parts of the body. When drugs affect blood cells, patients are more likely to get infections, may bruise or bleed easily, and may feel very weak and tired.
- Cells in hair roots: Chemotherapy can lead to hair loss. The hair grows back, but the new hair may be somewhat different in color and texture.
- Cells that line the digestive tract: Chemotherapy can cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Many of these side effects can be controlled with drugs.
Side Effects of Biological Therapy
The side effects of biological therapy vary with the type of treatment. These treatments may cause flu-like symptoms, such as chills, fever, muscle aches, weakness, loss of appetite, nausea, vomiting, and diarrhea. Patients may also get a skin rash. These problems can be severe, but they go away after treatment stops.
Side Effects of Radiation Therapy
The side effects of radiation therapy depend on the amount of radiation given and the area being treated. Side effects that may occur in the treated area include red or dry skin and hair loss. Radiation therapy also may cause fatigue. Although the side effects of radiation therapy can be unpleasant, the doctor can usually treat or control them. It also helps to know that, in most cases, side effects are not permanent.
People with melanoma may not feel like eating, especially if they are uncomfortable or tired. Also, the side effects of treatment, such as poor appetite, nausea, or vomiting, can be a problem. Foods may taste different. Nevertheless, patients should try to eat well during cancer therapy. They need enough calories to maintain a good weight and protein to keep up strength. Good nutrition often helps people with cancer feel better and have more energy.
The doctor, dietitian, or other health care provider can suggest ways to maintain a healthy diet. Patients and their families may want to read the National Cancer Institute booklet Eating Hints for Cancer Patients, which contains many useful ideas and recipes. The "National Cancer Institute Booklets" section tells how to get this publication.
Melanoma patients have a high risk of developing new melanomas. Some also are at risk of a recurrence of the original melanoma in nearby skin or in other parts of the body.
To increase the chance of detecting a new or recurrent melanoma as early as possible, patients should follow their doctor's schedule for regular checkups. It is especially important for patients who have dysplastic nevi and a family history of melanoma to have frequent checkups. Patients also should examine their skin monthly (keeping in mind the "ABCD" guidelines in the "Signs and Symptoms" section, and the skin self-exam described in "How To Do a Skin Self-Exam"). They should follow their doctor's advice about how to reduce their chance of developing another melanoma. General information about reducing the risk of melanoma is described in the "Melanoma: Who's at Risk?" section.
The chance of recurrence is greater for patients whose melanoma was thick or had spread to nearby tissue than for patients with very thin melanomas. Followup care for those who have a high risk of recurrence may include x-rays, blood tests, and scans of the chest, liver, bones, and brain.
The NCI has prepared a booklet for people who have completed their treatment to help answer questions about followup care and other concerns. Facing Forward Series: Life After Cancer Treatment provides tips for getting the most out of medical visits. It describes the kinds of help people may need.
A person who has been treated for melanoma may want to ask the doctor the following questions:
- How often should I have checkups?
- What special precautions should I take to avoid sun exposure?
- Are my family members at risk of melanoma? Should they schedule an appointment with their doctor for an examination?
Support for People with Melanoma
Living with a serious disease such as melanoma is not easy. Some people find they need help coping with the emotional and practical aspects of their disease. Support groups can help. In these groups, patients or their family members get together to share what they have learned about coping with the disease and the effects of treatment. Patients may want to talk with a member of their health care team about finding a support group. Groups may offer support in person, over the telephone, or on the Internet.
People living with melanoma may worry about caring for their families, keeping their jobs, or continuing daily activities. Concerns about treatments and managing side effects, hospital stays, and medical bills also are common. Doctors, nurses, and other members of the health care team can answer questions about treatment, working, or other activities. Meeting with a social worker, counselor, or member of the clergy can be helpful to those who want to talk about their feelings or discuss their concerns. Often, a social worker can suggest resources for financial aid, transportation, home care, or emotional support.
The Cancer Information Service at 1-800-4-CANCER can send publications and provide information to help patients and their families locate programs and services.
The Promise of Cancer Research
Doctors all over the country are conducting many types of clinical trials. These are research studies in which people take part voluntarily. Studies include new ways to treat melanomas. Research already has led to advances, and researchers continue to search for more effective approaches.
Patients who join these studies have the first chance to benefit from treatments that have shown promise in earlier research. They also make an important contribution to medical science by helping doctors learn more about the disease. Although clinical trials may pose some risks, researchers take very careful steps to protect their patients.
Researchers are testing new anticancer drugs. They are looking at combining chemotherapy with radiation therapy. Other studies are combining chemotherapy with biological therapy. Scientists also are studying several cancer vaccines and a type of gene therapy designed to help the immune system kill cancer cells.
Patients who are interested in being part of a clinical trial should talk with their doctor. They may want to read Taking Part in Clinical Trials: What Cancer Patients Need To Know. The NCI also offers an easy-to-read brochure called If You Have Cancer - What You Should Know About Clinical Trials. These NCI publications describe how research studies are carried out and explain their possible benefits and risks. NCI's Web site includes a section on clinical trials at http://cancer.gov/clinical_trials. This section of the Web site provides general information about clinical trials. It also offers detailed information about ongoing studies of melanoma treatment by linking to PDQAE, a cancer information database developed by the NCI. The Cancer Information Service at 1-800-4-CANCER can answer questions and provide information from the PDQ database.
How To Do a Skin Self-Exam
Your doctor or nurse may recommend that you do a regular skin self-exam. If your doctor has taken photos of your skin, comparing your skin to the photos can help you check for changes.
The best time to do a skin self-exam is after a shower or bath. You should check your skin in a well-lighted room using a full-length mirror and a hand-held mirror. It's best to begin by learning where your birthmarks, moles, and blemishes are and what they usually look and feel like.
Check for anything new:
A new mole (that looks abnormal):
- A change in the size, shape, color, or texture of a mole
- A sore that does not heal
Check yourself from head to toe. Don't forget to check all areas of the skin, including the back, the scalp, between the buttocks, and the genital area.
- Look at your face, neck, ears, and scalp. You may want to use a comb or a blow dryer to move your hair so that you can see better. You also may want to have a relative or friend check through your hair because this is difficult to do yourself.
- Look at the front and back of your body in the mirror, then raise your arms and look at your left and right sides.
- Bend your elbows and look carefully at your fingernails, palms, forearms (including the undersides), and upper arms.
- Examine the back, front, and sides of your legs. Also look between your buttocks and around your genital area.
- Sit and closely examine your feet, including the toenails, the soles, and the spaces between the toes.
By checking your skin regularly, you will become familiar with what is normal for you. It may be helpful to record the dates of your skin exams and to write notes about the way your skin looks. If you find anything unusual, see your doctor right away.
SOURCE: National Cancer Institute
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